The University of Chicago Genetic Services Laboratories

LaboLaboratories5841 S. Maryland Ave., Rm. G701, MC 0077, Chicago, Illinois 60637

-9130 [email protected] dnatesting.uchicago.edu CLIA #: 14D0917593 CAP #: 18827-49

Molecular Testing for Lissencephaly

Clinical Features: Classic Lissencephaly (LIS) or Lissencephaly Type 1 is a smooth or nearly smooth cerebral surface caused by deficient neuronal migration. The spectrum of malformations ranges from complete agyria (absent gyri) to regional pachygyria to subcortical band heterotopia (SBH).  Lissencephaly—“smooth brain" with absent (agyria) or abnormally wide gyri (pachygyria)  SBH—“double cortex”; band of heterotopic gray matter below the cortex separated by a thin zone of normal white matter  Miller-Dieker syndrome—lissencephaly, characteristic facial features and severe neurologic abnormalities  X-linked lissencephaly with abnormal genitalia (XLAG)—lissencephaly and moderately increased thickness of the cortex, absence of the corpus callosum, infantile spasms, hypothalamic dysfunction including deficient temperature regulation, and ambiguous genitalia in males.

Lissencephaly and SBH are classified by anterior-posterior gradient and severity. This classification may help determine the best order for genetic testing.

Dr. William Dobyns at the Seattle Children’s Research Institute is available to review MRI scans and give recommendations regarding genetic testing. Please contact Dr. Dobyns ([email protected]) or his coordinators, Carissa Adams ([email protected]) and Brandi Bratrude ([email protected]) to arrange this, if desired.

Molecular Genetics: The genetic causes of lissencephaly are complex, and may result from abnormalities in one of the genes below:

Gene / Condition Inheritance Clinical Features and Molecular Pathology Pattern PAFAH1B1 (LIS1) AD PAFAH1B1 (LIS1) abnormalities cause the most severe form of lissencephaly and are generally associated with a p>a gradient (1). PAFAH1B1 mutations are present in approximately 30% of patients with PAFAH1B1-related lissencephaly and rarely in patients with SBH. Microdeletions involving 17p13.3 are present in 100% of patients with MDS and approximately 50% of patients with lissencephaly. Intragenic deletions of one or more exons of LIS1 are present in approximately 15% of patients with PAFAH1B1-related lissencephaly (2). DCX X-linked DCX abnormalities result in severe lissencephaly or SBH in boys, but a less severe SBH in girls (3). DCX abnormalities are generally associated with an a>p gradient. In males, DCX mutations are present in approximately 30% with SBH and approximately 10% with lissencephaly. In females, DCX mutations are present in approximately 80% with SBH, especially those with diffuse bands or bilateral frontal only bands. Intragenic deletions of the DCX gene are present in approximately 10% of female patients with SBH in whom no mutations were identified by DCX sequencing (4, 5). TUBA1A AD TUBA1A mutations have been identified in patients with gyral malformations and are associated with two forms of lissencephaly. The first is lissencephaly with a p>a gradient similar to LIS1-associated lissencephaly, although this is rare cause of typical lissencephaly. The second is a severe form of lissencephaly associated with severe cerebellar hypoplasia (LCH) and often underdevelopment of the corpus callosum. About 30-40% of children with LCH have mutations in TUBA1A. (6). ARX X-linked ARX mutations cause various phenotypes including XLAG, X-linked infantile spasms, and non-syndromic X-linked mental retardation (7-9). Females with more severe mutations may be affected as well, and have agenesis of the corpus callosum and seizures (10).

6/15 NDE1 AR Mutations in NDE1 have been reported in children with severe congenital microcephaly, with brains smaller than 10 SD below the mean, with simplified gyri, and profound developmental handicap with normal body growth. Patients may also have lissencephaly or microhydraencephaly. Paciorkowski, et al. (2013) reported a patient with a full gene deletion and a truncating mutation in NDE1 who had severe microcephaly, agenesis of the corpus callosum, and a cortical dysplasia with a polymicrogyria-like appearance (11). NDE1 is highly expressed in the developing human and mouse cerebral cortex, particularly at the centrosome, and has a role in mitotic spindle assembly during early neurogenesis. Deficiency of NDE1 therefore appears to cause failure of neurogenesis and a deficiency of cortical lamination.

RELN AR RELN mutations have been identified in patients with a less severe form of VLDLR lissencephaly with cerebellar hypoplasia (LCH) (12). VLDLR-associated cerebellar hypoplasia (VLDLR-CH) falls within the LCH spectrum, and is characterized by non- progressive congenital ataxia, ID, dysarthria, strabismus and seizures. These patients have mild lissencephaly as well. VLDR is part of the reelin (RELN) signaling pathway, which guides neuroblast migration in the cerebral cortex and cerebellum. LCH is distinguished from VLDLR-CH by more severe lissencephaly with an a>p gradient, a small and malformed hippocampus, and profound cerebellar hypoplasia with complete absence of detectable folia (13). ACTB AD Baraitser-Winter syndrome is a developmental disorder characterized by congenital ACTG1 ptosis, high-arched eyebrows, hypertelorism, ocular colobomata and anterior- predominant lissencephaly. Other features include postnatal short stature, microcephaly, ID, seizures and hearing loss (14). Mutations in both ACTB and ACTG1, which code for cytoplasmic actin, have been identified in patients with Baraitser-Winter syndrome LAMC3 AR Barak et al (2011) identified a homozygous frameshift mutation in LAMC3 in a patient with bilateral occipital pachygyria. Further screening of the LAMC3 gene in 12 individuals with various malformations of cortical development (including lissencephaly and polymicrogyria), identified a homozygous truncating mutation in 1 patient with occipital pachygyria (15). B3GALNT2 AR Congenital muscular dystrophy-dystroglycanopathy with brain and eye anomalies type B3GNT1 A (MDDGA) is a genetically heterogeneous group of autosomal recessive conditions FKTN caused by defective glycosylation of DAG1, including Walker-Warburg syndrome, FKRP muscle-eye-brain and Fukuyama muscular dystrophy. Features of these conditions GMPPB include brain and eye malformations, cognitive impairment, and congenital muscular LARGE dystrophy. Brain malformations seen in MDDGA include cobblestone lissencephaly, POMGNT1 polymicrogyria, hydrocephalus, and cerebellar hypoplasia. Cobblestone POMGNT2 lissencephaly (COB, previously designated as lissencephaly "type 2"), is a brain POMK malformation consisting of a complex cortical dysplasia with glioneuronal heterotopia POMT1 on the brain surface, moderate to severe lissencephaly, dysmyelination, hypoplastic POMT2 brainstem, and dysplastic cerebellum with cysts. Mutations in FKTN, FKRP, LARGE, ISPD POMGnT1, POMT1 and POMT2 account for approximately 32-50% of patients with TMEM5 cobblestone lissencephaly (16). Mutations in TMEM5 and ISPD account for approximately 20% of patients with cobblestone lissencephaly (17). ATP6V0A2 AR Homozygous or compound heterozygous mutations in the ATP6V0A2 gene cause autosomal recessive cutis laxa type IIA (ARCL2A). This condition is characterized by overfolding and wrinkling of the skin and dysmorphic craniofacial features. Individuals with ARCL2A have early developmental delays, and seizures associated with a neurodegenerative course (18). Van Maldergem et al. (2008) reported cortical malformations reminiscent of Walker-Warburg syndrome in 8 patients with ARCL2A (18). LAMA2 AR LAMA2-related muscular dystrophy is an autosomal recessive group of conditions ranging from late-onset proximal weakness and motor delays to profound neonatal hypotonia, failure to thrive, ophthalmoparesis, and respiratory failure. A small proportion of individuals with early-onset LAMA2-related muscular dystrophy have brain malformations, including pachygyria and cortical dysplasia (19). The majority of affected individuals have normal cognitive abilities and cognitive development is not consistently correlated with brain MRI findings (20).

LAMB1 AR In two consanguineous families with cobblestone lissencephaly, Radmanesh et al (2013) identified two different homozygous loss-of-function mutations in the LAMB1 gene (21). Radmanesh et al. noted that although the brain malformations were similar to those identified in patients with muscular-dystrophy-dystroglycanopathies, these patients did not have significant eye or muscle disease.

6/15 SNAP29 AR Sprecher et al (2005) identified a homozygous truncating mutation in two unrelated consanguineous Arab Muslim families with cerebral dysgenesis, neuropathy, ichthyosis, and palmoplantar keratoderma (CEDNIK) syndrome. Individuals with CEDNIK syndrome have progressive microcephaly in conjunction with a range of brain malformations, including cortical dysplasia, pachygyria, absence of the corpus callosum, and perisylvian polymicrogyria. Additional features include dysmorphic facies, palmoplantar keratosis and ichthyosis, severe developmental delays, optic disc hypoplasia, and sensorineural hearing loss (22). SRD5A3 AR Mutations in SRD5A3 are associated with congenital disorder of glycosylation type Iq (CDG1Q). CDG1Q is a rare autosomal recessive condition characterized by abnormal type 1 glycosylation in association with congenital eye malformations including ocular colobomas and optic disc hypoplasia, intellectual disabilities, and variable brain malformations. Al-Gazali et al. (2008) reported a consanguineous family with multiple affected individuals. Brain malformations seen in affected individuals included cerebellar vermis hypoplasia, hypoplasia of the corpus callosum, absent septum pellucidum, and bilateral frontal polymicrogyria (23). Cantagrel et al. (2010) subsequently identified a homozygous mutation in SRD5A3 in affected individuals in this family, as well as homozygous or compound heterozygous SRD5A3 mutations in 5 other individuals (24).

Test panels: We offer both a Cobblestone Lissencephaly panel and a Comprehensive Lissencephaly panel which includes the genes listed below.

Cobblestone Lissencephaly Panel (18 genes) ATP6V0A2 ISPD POMK B3GALNT2 LAMA2 POMT1 B3GNT1 LAMB1 POMT2 FKRP LARGE SNAP29 FKTN POMGNT1 SRD5A3 GMPPB POMGNT2 TMEM5 Comprehensive Lissencephaly Panel (26 genes sequencing and del/dup) Includes analysis of ACTB, ACTG1, ARX, ATP6VOA2, B3GALNT2, B3GNT1, DCX, FKRP, FKTN, GMPPB, ISPD, LAMA2, LAMB1, LARGE, PAFAH1B1, POMGNT1, POMGNT2, POMK, POMT1, POMT2, RELN, SNAP29, SRD5A3, TMEM5, TUBA1A.

Sequencing and deletion/duplication testing of several of the genes in the Lissencephaly panels are also offered separately. We offer full gene sequencing for all coding exons and the intron/exon boundaries of ARX, DCX, NDE1, PAFAH1B1 and TUBA1A. We also offer deletion/duplication analysis of the ARX, DCX and PAFAH1B1 genes by MLPA to identify deletions/duplications of one or more exons. In addition, deletion/duplication analysis of all the genes in the Lissencephaly Panel can be performed by array-CGH.

Test methods:

Comprehensive sequence coverage of the coding regions and splice junctions of all genes in this panel is performed. Targets of interests are enriched and prepared for sequencing using the Agilent SureSelect system. Sequencing is performed using Illumina technology and reads are aligned to the reference sequence. Variants are identified and evaluated using a custom collection of bioinformatic tools and comprehensively interpreted by our team of directors and genetic counselors. All novel and/or potentially pathogenic variants are confirmed by Sanger sequencing. The technical sensitivity of this test is estimated to be >99% for single nucleotide changes and insertions and deletions of less than 20 bp. Deletion/duplication analysis of the panel genes is performed by MLPA or oligonucleotide array-CGH. Partial exonic copy number changes and rearrangements of less than 400 bp may not be detected by array-CGH. Array-CGH will not detect low-level mosaicism, balanced translocations, inversions, or point mutations that may be responsible for the clinical phenotype. The sensitivity of this assay may be reduced when DNA is extracted by an outside laboratory.

For patients of Asian descent that order the Lissencephaly or Cobblestone Lissencephaly panels: Two common non-coding mutations in the FKTN gene, present in individuals of Asian descent, including the retrotransposon insertion in the 3’UTR region and the c.647+2084G>T mutation in intron 5 will also be analyzed. For the former, PCR amplification is performed to produce a unique, specific, 400 bp amplification product specific for the 6/15 retrotransposon insertion. For the latter, a portion of intron 5 is PCR amplified and sequenced in both the forward and reverse directions and analyzed for the c.647+2084G>T mutation.

Comprehensive Lissencephaly panel (includes sequencing of 26 genes sequencing and deletion/duplication analysis) Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $6000 CPT codes: 81479 Turn-around time: 8 weeks Note: We cannot bill insurance for the above test.

Cobblestone Lissencephaly Sequencing panel (18 sequencing analysis) Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $3975 CPT codes: 81407 Turn-around time: 8 weeks Note: We cannot bill insurance for the above test.

Cobblestone Lissencephaly Del/Dup panel (FKRP, FKTN, LARGE, POMT1, POMT2, POMGNT1, ISPD, TMEM5 deletion/duplication analysis) Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1545 CPT codes: 81407 Turn-around time: 6 weeks

PAFAH1B1 (LIS1) sequencing analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1000 CPT codes: 81405 Turn-around time: 4 weeks

DCX sequencing analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $660 CPT codes: 81405 Turn-around time: 4 weeks

NDE1 sequencing analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1000 CPT codes: 81405 Turn-around time: 4 weeks

PAFAH1B1 (LIS1) / DCX deletion/duplication analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1000 CPT codes: 81404 Turn-around time: 4 weeks

TUBA1A sequencing analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $900 CPT codes: 81404 Turn-around time: 4 weeks

TUBA1A deletion/duplication analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1000 CPT codes: 81403 Turn-around time: 4 weeks

ARX sequencing analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $900 CPT codes: 81404 Turn-around time: 4 weeks

6/15 ARX deletion/duplication analysis Sample specifications: 3 to10 cc of blood in a purple top (EDTA) tube Cost: $1000 CPT codes: 81403 Turn-around time: 4 weeks

Deletion/duplication analysis for two or more genes (by array-CGH) Sample specifications: 3 to 10 cc of blood in a purple top (EDTA) tube Cost: $1545 CPT codes: 81479 Turn-around time: 4-6 weeks

Results: Results, along with an interpretive report, will be faxed to the referring physician. Additional reports will be provided as requested. All abnormal results will be reported by telephone.

References 1. Lo Nigro C, Chong CS, Smith AC et al. Point mutations and an intragenic deletion in LIS1, the lissencephaly causative gene in isolated lissencephaly sequence and Miller-Dieker syndrome. Hum Mol Genet 1997: 6: 157-164. 2. Dobyns W, Das S. LIS1-Associated Lissencephaly/Subcortical Band Heterotopia. In: Pagon R, Bird T, Dolan C, eds. GeneReviews [Internet]. Seattle: University of Washington, 2009. 3. des Portes V, Pinard JM, Billuart P et al. A novel CNS gene required for neuronal migration and involved in X-linked subcortical laminar heterotopia and lissencephaly syndrome. Cell 1998: 92: 51-61. 4. Matsumoto N, Leventer RJ, Kuc JA et al. Mutation analysis of the DCX gene and genotype/phenotype correlation in subcortical band heterotopia. Eur J Hum Genet 2001: 9: 5-12. 5. Hehr U, Uyanik G, Aigner L et al. DCX-Related Disorders. In: Pagon R, Bird T, Dolan C, eds. GeneReviews [Internet]. Seattle: University of Washington, 2007. 6. Poirier K, Keays DA, Francis F et al. Large spectrum of lissencephaly and pachygyria phenotypes resulting from de novo missense mutations in tubulin alpha 1A (TUBA1A). Hum Mutat 2007: 28: 1055-1064. 7. Kitamura K, Yanazawa M, Sugiyama N et al. Mutation of ARX causes abnormal development of forebrain and testes in mice and X-linked lissencephaly with abnormal genitalia in humans. Nat Genet 2002: 32: 359-369. 8. Bienvenu T, Poirier K, Friocourt G et al. ARX, a novel Prd-class-homeobox gene highly expressed in the telencephalon, is mutated in X-linked mental retardation. Hum Mol Genet 2002: 11: 981-991. 9. Strømme P, Mangelsdorf ME, Shaw MA et al. Mutations in the human ortholog of Aristaless cause X-linked mental retardation and epilepsy. Nat Genet 2002: 30: 441-445. 10. Marsh E, Fulp C, Gomez E et al. Targeted loss of Arx results in a developmental epilepsy mouse model and recapitulates the human phenotype in heterozygous females. Brain 2009: 132: 1563-1576. 11. Paciorkowski AR, Keppler-Noreuil K, Robinson L et al. Deletion 16p13.11 uncovers NDE1 mutations on the non-deleted homolog and extends the spectrum of severe microcephaly to include fetal brain disruption. Am J Med Genet A 2013: 161A: 1523-1530. 12. Hong SE, Shugart YY, Huang DT et al. Autosomal recessive lissencephaly with cerebellar hypoplasia is associated with human RELN mutations. Nat Genet 2000: 26: 93-96. 13. Boycott K, Parboosingh J. VLDLR-Associated Cerebellar Hypoplasia. In: Pagon R, Bird T, Dolan C, eds. GeneReviews [Internet]. Seattle: University of Washington, 2008. 14. Rivière JB, van Bon BW, Hoischen A et al. De novo mutations in the actin genes ACTB and ACTG1 cause Baraitser-Winter syndrome. Nat Genet 2012: 44: 440-444, S441-442. 15. Barak T, Kwan KY, Louvi A et al. Recessive LAMC3 mutations cause malformations of occipital cortical development. Nat Genet 2011: 43: 590-594. 16. Devisme L, Bouchet C, Gonzalès M et al. Cobblestone lissencephaly: neuropathological subtypes and correlations with genes of dystroglycanopathies. Brain 2012: 135: 469-482. 17. Vuillaumier-Barrot S, Bouchet-Séraphin C, Chelbi M et al. Identification of mutations in TMEM5 and ISPD as a cause of severe cobblestone lissencephaly. Am J Hum Genet 2012: 91: 1135-1143. 18. Van Maldergem L, Yuksel-Apak M, Kayserili H et al. Cobblestone-like brain dysgenesis and altered glycosylation in congenital cutis laxa, Debre type. Neurology 2008: 71: 1602-1608. 19. Quijano-Roy S, Sparks S, Rutkowski A. LAMA2-Related Muscular Dystrophy. In: Pagon R, Bird T, Dolan C, eds. GeneReviews [Internet]. Seattle: University of Washington, 2012. 20. Messina S, Bruno C, Moroni I et al. Congenital muscular dystrophies with cognitive impairment. A population study. Neurology 2010: 75: 898-903. 21. Radmanesh F, Caglayan AO, Silhavy JL et al. Mutations in LAMB1 cause cobblestone brain malformation without muscular or ocular abnormalities. Am J Hum Genet 2013: 92: 468-474. 22. Sprecher E, Ishida-Yamamoto A, Mizrahi-Koren M et al. A mutation in SNAP29, coding for a SNARE protein involved in intracellular trafficking, causes a novel neurocutaneous syndrome characterized by cerebral dysgenesis, neuropathy, ichthyosis, and palmoplantar keratoderma. Am J Hum Genet 2005: 77: 242-251. 23. Al-Gazali L, Hertecant J, Algawi K et al. A new autosomal recessive syndrome of ocular colobomas, ichthyosis, brain malformations and endocrine abnormalities in an inbred Emirati family. Am J Med Genet A 2008: 146A: 813-819. 24. Cantagrel V, Lefeber DJ, Ng BG et al. SRD5A3 is required for converting polyprenol to dolichol and is mutated in a congenital glycosylation disorder. Cell 2010: 142: 203-217.

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